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   Table of Contents - Current issue
Coverpage
January-March 2021
Volume 29 | Issue 1
Page Nos. 1-77

Online since Thursday, December 31, 2020

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EDITORIAL  

COVID-19 vaccines p. 1
Cenk Demirdover
DOI:10.4103/1300-6878.305908  
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ORIGINAL ARTICLES Top

Experience on subfascial mammary augmentation and influence of incisions on technique p. 4
Ali Gokkaya, Metin Gorgu
DOI:10.4103/tjps.tjps_93_19  
Introduction: Mammary augmentation is among the most popular types of cosmetic procedures and mammary prosthesis the most commonly accepted technique. A mammary prosthesis can be placed on transaxillary, periareolar, submammary incisions in subglandular, subpectoral, subfascial planes or in a combination of planes. Given the potential interaction between the prosthesis and the surrounding tissues, the plane in which the prosthesis is implanted has an important role among the factors affecting this interaction. The plastic surgeon decides on the incision and plane to be used by assessing the advantages and disadvantages. Materials and Methods: Prostheses were implanted in the subfascial plane in 47 patients who underwent augmentation mammaplasty. Round Moderate Plus or High Profile Cohesive II™ Gel implants were used. Device volumes ranged from 275 to 600 cc. Of the 47 procedures, 23 were performed over an axillary incision, 20 over an inframammary incision, and 4 over a periareolar incision. Endoscopic-assisted dissection was performed in all of the 23 cases in which transaxillary incision was used. Results: All 47 patients who underwent subfascial prosthesis implantation were followed up for a mean of 5 years (range: 2–7 years). Long-term results were satisfactory with few complications. The overall patient satisfaction rate was 89.3%, and none of the patients required an implant removal or change. None of the patients complained of severe pain, regardless of the type of incision, and resumed their daily activities on postoperative day 2. Conclusion: The subfascial augmentation technique provides good and long-term results. It requires longer operating times and is a more difficult technique compared to other planes. As the choice of incision does not largely affect the overall result, the position of the scar depends on the patient's preference, the properties of the implant, and the experience of the surgeon. The endoscopic assistance should be preferred when using the transaxillary approach.
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Assessment of incision types, risk factors, and complication rates in nipple and skin-sparing mastectomy p. 14
Haluk Vayvada, Cenk Demirdover, Alper Geyik, Adnan Menderes
DOI:10.4103/tjps.tjps_19_20  
Introduction: The incidence of breast cancer in the female population of reproductive age is rising. Surgery is the primary approach, and other treatment options can be adopted in certain circumstances. In the surgical field, lately, there has been a growing interest for nipple–skin-sparing mastectomy (NSSM). This study aims to emphasize the effect of incision types and patient characteristics (demographics, concomitant disease, smoking, history of radiotherapy, and chemotherapy) on complication rates. Patients and Methods: The subjects included 184 breasts in 92 female patients who underwent the NSSM procedure at our clinic from January 2010 to May 2019. Patients who underwent bilateral NSSM and immediate reconstruction with prosthesis were included in the study. Results: The most commonly used incision pattern was the inverted T-scar. Seven patients who had a contralateral prophylactic mastectomy (7.6%) were found to have atypical proliferative lesions or occult breast carcinoma in the clinically healthy contralateral breast on pathological examination. Complications were seen in 36 patients (39.1%). Skin–nipple–areolar complex necrosis was the most frequent complication. A previous history of radiation therapy was associated with higher rates of complications. Conclusion: NSSM and immediate single-stage implant reconstruction is a procedure with high morbidity and complication rates. The incision type and smoking have the main effect on complication rates. Although most complications are manageable, the surgical approach and patient-related risk factors should be taken into consideration for avoiding them.
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Utility of short-scar incisions mimicking breast augmentation incisions through periareolar or submammary approach for a better aesthetic outcome and patient satisfaction p. 20
Ayhan Okumus
DOI:10.4103/tjps.tjps_77_19  
Purpose: The purpose of the study is to evaluate the long-term aesthetic outcome of single-session nipple-sparing mastectomy (NSM) and immediate breast reconstruction operations performed using short-scar incisions mimicking breast augmentation incisions through periareolar or submammary approach. Materials and Methods: A total of 23 breast cancer patients (mean age: 32 years, range 21–44 years) who underwent single-session NSM and immediate breast reconstruction operations (bilateral in 9) performed through periareolar or submammary approach were included. Data on patient age, breast cancer characteristics, side of mastectomy and reconstruction, postoperative complications were retrieved from hospital records. Aesthetic outcome (by both patients and plastic surgeon), patient satisfaction (visual analog scale [VAS] scores), and psychological outcome (via body image scale) were evaluated after a median 4-year (range, 9 months–11 years) follow-up. Results: Majority of the patients identified that size of the breast (95.7%), shape of breast (95.7%), breast symmetry (95.7%), scars on the breast (100.0%), nipple-areola complex (100%), and overall aesthetic results (95.7%) fulfilled expectations very much. Physician evaluation also revealed that aesthetic outcome was excellent for majority of patients in terms of breast symmetry (80.7%), breast volume (95.7%), position of submammary fold (95.7%), and overall aesthetic result (95.7%) and all patients in terms of scar appearance on the breast (100.0%). Mean (standard deviation) VAS scores for patient satisfaction were 9.4 (0.8). Total body image scale indicated very good body image in terms of affective (e.g. feeling self-conscious), behavioral (e.g. difficulty in looking at the naked body), and cognitive (e.g. satisfaction with appearance) aspects in all patients. Conclusion: Our findings indicate the utility of short-scar (~4 cm) incisions mimicking breast augmentation incisions in a single-session NSM and immediate breast reconstruction as associated with a low-postoperative complication rate, an excellent aesthetic outcome and a very high patient satisfaction.
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Galactorrhea and galactocele formation after augmentation mammoplasty and augmentation mastopexy p. 28
Safvet Ors
DOI:10.4103/tjps.tjps_18_20  
Purpose: Some of the most common complications associated with augmentation mammoplasty (AUM) and augmentation mastopexy (AUMX) include infections, seroma, hematoma, capsular contracture, asymmetry, hypertrophic scars, implant rupture, and deformities. Galactocele and galactorrhea can rarely be observed after AUM and in reduction mammoplasties other than the AUMX, while galactorrhea is often observed after chest wall deformity correction surgery and thoracic surgery. Patients and Methods: In our clinic, galactorrhea was developed in five out of 540 patients who underwent AUM or AUMX, and one of these patients also had galactorrhea and galactocele in the accessory breast tissue. No patients were postmenopausal, and none of them had a history of pituitary, adrenal, thyroid, or ovarian surgery. Lactation started in average 10–15 days after surgery and lasted about 4–5 weeks. The patients were followed up for 1–10 years. In one patient who was found to be pregnant, galactorrhea ceased spontaneously 2 weeks after the termination of the pregnancy by curettage. Results: This clinical study presents the cases of five patients with galactorrhea and galactocele in the accessory breast tissue, with particular focus on treatment and possible risks, and discusses whether large nipples may cause a risk for galactorrhea. This study presents the second largest series of cases with galactorrhea in literature after the study reported by Caputy and Flowers. Level of evidence: Level V.
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In-depth survey of demographic, clinical, and operative measures in cleft lip and palate patients in Northwestern Turkey p. 33
E Cigdem Karadag Sari, Emrah Kagan Yasar, Guler Gamze Eren, Altug Altinkaya, Hakan Agir
DOI:10.4103/tjps.tjps_9_20  
Background: Orofacial clefts are the most common congenital craniofacial anomalies, globally. However, few reports describe cleft demographic, clinical, and surgical information in a Turkish population. Aims and Objectives: The aim of this study is to investigate the demographic, clinical, surgical information and outcomes of cleft lip and/or palate (CL/P) patients in Northwestern Turkey. Materials and Methods: We assessed demographic, clinical, operative characteristics, and postoperative complications data in this retrospective review of electronic medical records at a tertiary referral center from 2005 to 2015. Results: Our study included 150 CL/P patients (88 men, 62 women). Cleft lip and palate (CLP) was the most prevalent type of cleft (60%), followed by isolated cleft palate (31.3%) and isolated cleft lip (8.7%). The rates of maternal folic acid use, smoking, alcohol intake, and consanguinity were 83.3%, 5.3%, 1.3%, and 3.3%, respectively. Nasoalveolar molding was applied mostly in bilateral—not unilateral—CLP patients. The modified, extended Mohler technique was common for cleft lip repairs. Most cleft palate repairs used Bardach's two-flap palatoplasty combined with radical intravelar veloplasty. Most cases required grommet insertion. For cleft palate patients, myringotomy or paracentesis was performed in 12.8% of repairs, and acellular dermal matrix was used in 28.5% of repairs. Conclusion: Knowledge of CL/P characteristics is crucial for treatment planning and satisfactory health care. To our knowledge, this is the first study to assess CLP data in a Turkish population.
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Reconstruction of hand and wrist soft-tissue defects using radial artery perforator flap p. 39
Alper Urals FEBOPRAS, Fatma Bilgen, Mehmet Bekerecioğlu
DOI:10.4103/tjps.tjps_23_20  
Aim: Soft-tissue defects in the hand and wrist are frequently encountered injuries that may occur due to trauma, burns, or other causes. We aimed to report our experiences in reconstruction of these defects using a radial artery perforator flap (RAPF). Materials and Methods: Eight patients who underwent surgery for reconstruction of the hand and wrist soft-tissue defects at our institution between December 2017 and December 2019 were included in the study. The patients were evaluated in terms of age, sex, etiology, flap size, defect region, and postoperative complications. Results: All defects were reconstructed by utilizing RAPF. The most common etiology of the defects was work-related accidents. The mean age of the patients was 40.4 (10–69) years. The mean flap size was 63.5 ± 14.76 cm2. Six patients healed uneventfully, while we observed partial necrosis of the RAPF flap in one of the cases and a marginal epidermolysis in another. The donor sites were skin grafted in each patient. The patient where partial necrosis observed was re-operated for debridement and skin grafting subsequentially. The duration of follow-up of the patients was 6 months. Conclusions: Radial forearm perforator flap is a reliable and effective reconstructive option to reconstruct small to moderately sized defects of the hand and wrist.
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An algorithm for the reconstruction of nonfingertip upper extremity soft tissue defects p. 43
Soysal Bas, Mert Sizmaz, Alican Aydin, Selami Serhat Sirvan, Semra Karsidag
DOI:10.4103/tjps.tjps_16_20  
Aims: The aim of this study was to evaluate the advantages and disadvantages of reconstructive methods used in the upper extremity soft tissue defects other than the fingertips, according to location. Materials and Methods: This retrospective study included 212 patients operated between January 2012 and January 2019 due to upper extremity soft tissue defects excluding the fingertip. Patients were evaluated in terms of age, gender, etiology, reconstruction area, method, and complications. Statistical Analysis Used: The relationship between the reconstructive method or location and the complication was evaluated by one-way analysis of variance test. The relationship between categorical variables was tested by Kruskal–Wallis test. The significance of multiple comparisons was adjusted using Bonferroni correction. Results: The average age of patients was 35.4 ± 19.12 years; 168 were male and 44 were female. 158 patients were operated for trauma, 34 for malignant tumor, 12 for infection, and 8 for extravasation. Complications were observed in 19 of the 220 reconstructive procedures (8.6%): two of the local flaps, three distant flaps, two regional flaps, five perforator flaps, and seven free flaps. 26% of these complications were seen in fingers, 15% in hands, 42% in wrists, 5.2% in forearms, 5.2% in elbows, and 5.5% in arms. Conclusions: There are many procedures for upper extremity reconstruction that can be selected according to defect location and character. It should be kept in mind that complex reconstructions that are preferred especially in complicated injuries may end up with challenging complications. In these types of complicated injuries, it would be better to prefer a reconstructive ladder instead of a reconstructive elevator.
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Pedicled anterolateral thigh flap: A reliable flap for reconstruction of difficult regional defects in pediatric patients p. 51
Mohamed Abdalla Elnahas
DOI:10.4103/tjps.tjps_10_20  
Background: Once it has been first described by Song et al., in 1984, anterolateral thigh (ALT) flap gains wide popularity as a free flap with only a few reports in the literature regarding its application as a pedicled flap in regional soft-tissue reconstruction in pediatric patients. Materials and Methods: The author describes his experience about the role of pedicled ALT flap in reconstruction of different local defects in pediatric patients. Representative cases are presented for illustration. Results: Nine patients with ischial, trochanteric, and groin defects have been reconstructed by pedicled ALT flap between January 2018 and January 2019. The patients were between 7- and 15-year-old. The size of the flaps measured from 4 cm × 6 cm to 19 cm × 17 cm. The type of the flap was myocutaneous flaps in six cases and as perforator flaps in three cases. Primary closure of the donor site has been done in seven cases while split-thickness skin grafts were done in two cases. Eight flaps have been totally survived while partial necrosis has been occurred in the distal end of one case. Conclusion: Pedicled ALT flap provide a reliable and versatile option for plastic surgeons in reconstruction of difficult regional soft-tissue defects in pediatric patients especially when bulkiness and resistance of infection is indicated, with accepted functional and cosmetic results.
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REVIEW ARTICLE Top

Clinical and radiological features of some rare forms of craniosynostosis in clinical practice p. 55
Tufan Hicdonmez, Gaye Filinte
DOI:10.4103/tjps.tjps_57_19  
There are rare forms of craniosynostosis with single or multiple suture involvement. These are sphenofrontal plagiocephaly; posterior plagiocephaly with unilateral lambdoid synostosis; combined sagittal and metopic synostosis; combined sagittal and unilateral coronal synostosis; and bilateral lambdoid and sagittal synostosis with Mercedes–Benz pattern. In our study, we aimed to present both clinical and three-dimensional computed tomographic characteristics of these rare forms of craniosynostosis.
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CASE REPORTS Top

Fat graft and platelet-rich plasma treatment for localized facial scleroderma p. 59
Ali Gokkaya, Dilek Demirez, Metin Gorgu, Ertugrul Karanfil, Jehat Kizilkan, Ali Dogan
DOI:10.4103/tjps.tjps_98_19  
Scleroderma is an autoimmune disorder characterized by hardening of the skin on the hands, arms, and face. Immunosuppressors, vasodilators, and physiotherapy are among the treatments for scleroderma. Although these treatments can improve quality of life, the treatment response in locally affected areas may be poor. At present, there is no specific treatment for localized fibrotic skin lesions in scleroderma, although stem cell treatment shows promise for local symptoms. We describe the case of a patient with facial skin symptoms of scleroderma treated with platelet-rich plasma combined with fat grafts rich in stem cells.
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Giant dermatofibrosarcoma protuberans in the forearm p. 62
Ferhat Kargalioglu, Galip Gencay Ustun, Koray Gursoy, Ugur Kocer
DOI:10.4103/tjps.tjps_94_19  
Dermatofibrosarcoma protuberans (DFSP) is a rare, slow-growing, locally aggressive malignant fibroblastic mesenchymal skin tumor, which is considered as the most common skin sarcoma. As a treatment modality, local excision with 4–5 cm border is commonly replaced by Mohs micrographic surgery. A 24-year-old woman with a giant DFSP in the forearm is presented. The patient was admitted to clinic with a large protuberant mass on the left forearm. The preliminary diagnosis was soft-tissue sarcoma due to a history of rapid growth and absence of any skin lesion. DFSP originates from the dermis and commonly infiltrates underlying muscles, tendons, fascia, and bones. In this case, there was no skin infiltration. Mohs micrographic surgery was not used in the treatment since the tumor was confined to subcutaneous tissue and did not infiltrate to the skin. Although the Mohs micrographic surgery was not used, the tumor did not recur postoperative 6 months' follow-up. A long-term follow-up is strongly recommended in DFSP cases.
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Endovascular management of auricular arteriovenous malformations p. 66
Saima Ahmad
DOI:10.4103/tjps.tjps_95_19  
This is a retrospective review of eight patients with extracranial arteriovenous malformations (AVMs) of the auricular region. All cases presented with significant hemorrhages or cosmetic defects. Highflow AVMs of the auricular are quite rare in contrast to low flow vascular lesions of the head and neck, making early diagnosis and treatment critical as incidences of recurrence are high if not managed properly. The purpose of this study is to present our experience of experimental endovascular treatment in a series of eight patients with auricular AVMs. From January 2015 to December 2017, eight patients with auricular AVM were put through transcatheter arterial embolization and percutaneous direct puncture embolization with polyvinyl alcohol (PVA) and bleomycin in five patients, glue embolization in one patient and coiling along with PVA in two patients to occlude high-flow fistula. Clinical outcomes were obtained through physical examination, and symptoms and a degree of devascularization on follow-up angiography. We performed 10 therapeutic embolization procedures. Of these, 3 resulted in absolute devascularization while 5 resulted in 75% obstruction. In 5 patient's embolization was performed as a palliative procedure. The other 3 were embolized as a sole mean of treatment for occluding the AVM. Only two patients developed postembolization necrosis and infection, and there has been no reexpansion of lesions to date. While thus far only having been used as percutaneous local sclerotherapy, this study found that bleomycin and PVA mixture, if used intraarterially can be more effective in the management of auricular AVM's.
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Spontaneous massive vulvar edema in the postnatal period p. 73
Simay Ersahin, Deniz Gunes, Sinan Oksuz
DOI:10.4103/tjps.tjps_8_20  
Spontaneous and isolated massive vulvar edema is seen as a rare condition in pregnancy in the postpartum period. Underlying causes have to be well understood, and treatment plans has to be well organized because of its association with high maternal mortality rate. We report a case of postpartum massive vulvar edema in a 19-year-old-primigravida patient presented with vulvar pain and difficulty in mobilization in the postpartum 4th day. The vulvar edema resolved progressively with surgical incisions on the labia minoras. The aim of this report is to inform clinicians that surgical intervention can be a successful treatment modality.
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LETTER TO THE EDITOR Top

Plastic and reconstructive surgery procedures during the COVID-19 pandemic: A paradigm shift p. 76
Etkin Boynuyogun, Galip Gencay Ustun, Figen Ozgur
DOI:10.4103/tjps.tjps_74_20  
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